When does vaginal delivery invite incontinence?
Cesarean or no cesarean, only a few factors can reduce risk of pelvic floor damage, and not all are controllable. What to counsel the worried, incontinent gravida.
IN THIS ARTICLE
- What the evidence does—and does not confirm
- Protective factors
- Term Breech Trial
Pregnant and incontinent
Marisol, a 32-year-old physiotherapist expecting her second child, presents to your antenatal clinic at 20 weeks’ gestation. She complains of urinary incontinence, which has been worsening throughout this pregnancy, and wants to know what can be done about it.
How do you respond?
The bad news is that Marisol’s complaints are not uncommon. The good news: Detailed evaluation and considered discussion can help reveal the full extent of her symptoms and shed light on how to proceed, though, in some cases, your options may be limited. Since we are in the early stages of understanding pelvic floor dysfunction related to pregnancy and childbirth, giving clear advice and guidance can sometimes be difficult. The starting point here, as in any case involving urinary symptoms, is a detailed history to pin down the cause of the patient’s complaints.
In women, urinary incontinence generally stems from overactive bladder or urethral sphincter incompetence; the latter is generally acquired through pregnancy and childbirth.Examining the Evidence.)
Episiotomy also has been associated with diminished pelvic floor muscle strength, compared with spontaneous perineal lacerations.33
Other factors with protective potential. Some recommendations may reduce the overall risk of incontinence in the long term in the general population, though they do not apply in Marisol’s case. For example, weight reduction in moderately obese women can reduce the risk of urinary symptoms.34
Chronic cough also increases the risk of pelvic floor dysfunction and prolapse, particularly among older women,13 so smoking cessation should be recommended.
Selecting the mode of delivery in a case like Marisol’s involves weighing her risks and desires with your expertise. No clear evidence is available to guide the way. This makes judicious counseling about the short-and long-term risks of conservative management and surgical delivery doubly important.
DID PRIOR DELIVERY DO DAMAGE?
Marisol’s final question concerns her first delivery. She feels she was inadequately counseled and wants to know whether delivery by cesarean would have protected her from her current symptoms.
In a prospective cohort study, Eason and colleagues4 found that 93.4% of women undergoing abdominal delivery remained continent postpartum, whereas 20.6% of women delivering vaginally lost urinary continence. However, Marisol’s symptoms predated the initial pregnancy.
The Term Breech Trial35 found no significant differences in maternal outcomes, including incontinence and sexual function, between the planned cesarean and planned vaginal delivery groups. However, the high crossover from planned vaginal delivery to delivery by cesarean suggests this evidence should be interpreted with caution. Cesarean delivery comes with its own set of complications and long-term problems.
Counsel all women about the risks of vaginal delivery?
This is a thorny question. As the body of evidence increases on the long-term effects of pregnancy and delivery, these issues are entering the public domain. We may be approaching a time when the specter of litigation influences how we counsel women about the risks of natural childbirth. How this change will be viewed by women’s health groups—some of which already perceive the health-care system as overmedicalizing a natural event—can only be imagined.
The authors report no financial relationships relevant to this article.
1. Keane DP, O’Sullivan S. Urinary incontinence: anatomy, physiology and pathophysiology. Ballieres Best Pract Res Clin Obstet Gynaecol. 2000;14:207-226.
2. Rortveit G, Daltveit AK, Hannestad YS, Hunskaar S. Norwegian EPINCONT Study. Urinary incontinence after vaginal delivery or cesarean section. N Engl J Med. 2003;348:900-907.
3. Dolan LM, Walsh D, Hamilton S, Marshall K, Thompson K, Ashe R. A study of quality of life in primigravidae with urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2004;15:160-164.
4. Eason E, Labrecque M, Marcoux S, Mondor M. Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study. BMC Pregnancy Childbirth. 2004;4:4.-
5. Gregory WT, Nygaard I. Childbirth and pelvic floor disorders. Clin Obstet Gynecol. 2004;47:394-403.
6. Fritel X, Fauconnier A, Levet C, Benifla J. Stress urinary incontinence 4 years after the first delivery: a retrospective cohort survey. Acta Obstet Gynecol Scand. 2004;83:941-945.
7. Schytt E, Lindmark G, Waldenstrom U. Symptoms of stress incontinence 1 year after childbirth: prevalence and predictors in a national Swedish sample. Acta Obstet Gynecol Scand. 2004;83:928-936.
8. Handa VL, Harvey L, Fox H, Kjerulff KH. Parity and route of delivery: does cesarean delivery reduce bladder symptoms later in life? Am J Obstet Gynecol. 2004;191:463-469.
9. Sultan AH, Kamm MA, Hudson CN. Pudendal nerve damage during labour: prospective study before and after childbirth. Br J Obstet Gynaecol. 1994;101:22-28.
10. Damaser MS, Whitbeck C, Chichester P, Levin R. Effect of vaginal distension on blood flow and hypoxia of urogenital organs of the female rat. J Appl Physiol. 2005;98:1884-1890.
11. Sartori JP, Sartori MG, Baracat EC, De Lima GR, Girao M. Bladder neck mobility and functional evaluation of the pelvic floor in primiparae according to the type of delivery. Clin Exp Obstet Gynecol. 2004;31:120-122.
12. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol. 2003;101:46-53.
13. Uustal Fornell E, Wingren G, Kjolhede P. Factors associated with pelvic floor dysfunction with emphasis on urinary and fecal incontinence and genital prolapse: an epidemiological study. Acta Obstet Gynecol Scand. 2004;83:383-389.
14. Dupuis O, Madelenat P, Rudigoz RC. Fecal and urinary incontinence after delivery: risk factors and prevention [in French]. Gynecol Obstet Fertil. 2004;32:540-548.
15. Fitzpatrick M, O’Herlihy C. The effects of labour and delivery on the pelvic floor. Best Pract Res Clin Obstet Gynaecol. 2001;15:63-79.
16. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905-1911.
17. Fitzpatrick M, Fynes M, Cassidy M, Behan M, O’Connell PR, O’Herlihy C. Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury. Eur J Obstet Gynecol Reprod Biol. 2000;89:159-163.
18. Chaliha C, Digesu A, Hutchings A, Soligo M, Khullar V. Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries. BJOG. 2004;111:754-755.
19. Foldspang A, Hvidman L, Mommsen S, Nielsen JB. Risk of postpartum urinary incontinence associated with pregnancy and mode of delivery. Acta Obstet Gynecol Scand. 2004;83:923-927.
20. Liebling RE, Swingler R, Patel RR, Verity L, Soothill PW, Murphy DJ. Pelvic floor morbidity up to one year after difficult instrumental delivery and caesarean section in the second stage of labor: a cohort study. Am J Obstet Gynecol. 2004;191:4-10.
21. Murphy DJ, Liebling RE. Cohort study of maternal views on future mode of delivery after operative delivery in the second stage of labor. Am J Obstet Gynecol. 2003;188:542-548.
22. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. London, UK: RCOG Press; 2001. Available at: http://www.rcm.org.uk/templates/news/detail.cfm/115. Accessed June 20, 2005.
23. National Center for Health Statistics. Births—method of delivery. Available at http://www.cdc.gov/nchs/fastats/delivery.htm. Accessed July 8, 2005.
24. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice caesarean: an evidence-based review. Obstet Gynecol Surv. 2004;59:601-616.
25. Rashid M, Rashid RS. Higher order repeat caesarean sections: how safe are five or more? BJOG. 2004;111:1090-1094.
26. Flamm BL, Goings JR, Liu Y, Wolde-Tsadik G. Elective repeat cesarean delivery versus trial of labor: a prospective multicenter study. Obstet Gynecol. 1994;83:927-932.
27. Clarl SL, Koonings PP, Phelan JP. Placenta previa/accreta and prior caesarean section. Obstet Gynecol. 1985;66:89-92.
28. Snooks SJ, Swash M, Mathers SE, Henry MM. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. Br J Surg. 1990;77:1358-1360.
29. Salvesen KA, Morkved S. Randomised controlled trial of pelvic floor muscle training during pregnancy. BMJ. 2004;329:378-380.
30. Glazener CM, Herbison GP, Macarthur C, Grant A, Wilson PD. Randomised controlled trial of conservative management of postnatal urinary and faecal incontinence: six year follow up. BMJ. 2005;330:337.-
31. Howell CJ. Epidural versus non-epidural analgesia for pain relief in labour. Cochrane Database Syst Rev. 2000;(2):CD000331.-
32. Dannecker C, Hillemanns P, Strauss A, Hasbargen U, Hepp H, Anthuber C. Episiotomy and perineal tears presumed to be imminent: the influence on the urethral pressure profile, analmanometric and other pelvic floor findings—follow-up study of a randomized controlled trial. Acta Obstet Gynecol Scand. 2005;84:65-71.
33. Department of Health. Changing Childbirth. Part 1: Report of the Expert Maternity Group. London, UK: HMSO; 1993.
34. Subak LL, Johnson C, Whitcomb E, Boban D, Saxton J, Brown JS. Does weight loss improve incontinence in moderately obese women? Int Urogynecol J Pelvic Floor Dysfunct. 2002;13:40-43.
35. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned caesarean section versus planned vaginal birth for breech presentation at term: the international randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:917-927.